Sponsored By
An organization or individual has paid for the creation of this work but did not approve or review it.



How helping the poor could fill a major gap in North Dakota's mental health system

North Dakota is "leaving money on the table" by not getting a Medicaid waiver for adults to access behavioral health services. Legislators approved a waiver application, but the state hasn't applied.

The two main residential buildings of ShareHouse Inc. are seen Monday, Feb. 5, 2018, at 4215 9th Ave. S. and 4227 9th Ave. S., Fargo. Michael Vosburg / Forum Photo Editor
The two main residential buildings of ShareHouse Inc. are seen Monday, Feb. 5, 2018, at 4215 9th Ave. S. and 4227 9th Ave. S., Fargo.
Michael Vosburg / The Forum
We are part of The Trust Project.

FARGO — North Dakota’s largest private providers of inpatient psychiatric and substance abuse treatment say they are bleeding financially from providing services to the sickest patients who lack the ability to pay.

ShareHouse, the state’s largest provider of inpatient substance use disorder treatment, has seen the number and severity of cases spike during the pandemic, said Ty Hegland, president of ShareHouse.

“We are getting slammed with acuity right now,” he said. “We’ve got to act now. If we don’t, we're going to stack up bodies.”

Prairie St. John’s in Fargo, the state’s largest private psychiatric hospital, was forced to close a 48-bed residential substance use disorder treatment program because of inadequate funding for patients without insurance or other means of paying for services.

“There’s patients not being served,” said Jeff Herman, president of Prairie St. John’s. “We can’t provide that service for free any longer,” after years of maintaining the program without adequate payments.


The two behavioral health administrators will be going to the North Dakota Legislature with priority requests to improve access to treatment for those needing psychiatric or substance abuse care.

For several years, North Dakota has provided vouchers to pay for substance use disorder treatment for those who lack insurance or the ability to pay. But providers say gaps in service remain. To address that problem, behavioral health providers will be pleading for increased funding for reimbursements through Medicaid and Medicaid expansion, the health insurance program for the poor.

One key request: Having the North Dakota Department of Human Services apply for a waiver to allow reimbursement for adult Medicaid patients served at “institutions of mental disease” with more than 16 beds.

Under a law passed in 1965, Medicaid won’t pay for substance use disorder or psychiatric treatment at any treatment center or hospital with more than 16 beds.

The North Dakota Legislature in 2021 authorized a waiver application, but state officials haven’t yet begun the lengthy and complex process.

Earlier this year, a state human services administrator told legislators that a waiver application likely would take three to five years, require five full-time employees and cost an estimated $3.5 million.

"Institutions of mental disease," the term used in the 1965 federal law, in North Dakota with more than 16 beds include the State Hospital in Jamestown, which has 140 licensed beds; Prairie St. John’s in Fargo, which has 110 beds, increasing to 132 beds when its new hospital opens Jan. 10; ShareHouse in Fargo, which as 87 beds; and Summit Prairie Recovery Center in Raleigh, which has 36 beds.

The purpose of a waiver is to ensure that the sickest people among the needy in the state receive treatment, Hegland said.


Between 30% and 50% of ShareHouse patients are on Medicaid, he said. “How do they access services?”

The answer is to provide funding to open beds for adult Medicaid patients that are already available, Hegland said: “We have enough beds,” he said. “We don’t have the right beds.”

Legislators have expressed concerns that the impact of securing the Medicaid waiver would have to be budget neutral, a difficult bar to reach since the intent would be to offer services to more people.

But Hegland counters that 39 states, including Minnesota, have obtained waivers or have pending waiver applications.

“If 39 other states can do it, what are we missing?” he asked.

Herman added, “Are they really that much smarter than we are?”

By failing to obtain the Medicaid waiver, North Dakota is foregoing federal funds that could help people, Hegland said. “We’re leaving money on the table,” he said, adding that he believes the application would cost North Dakota $1.5 million to $3 million, based on other states' costs.

Private providers end up delivering charity care when patients can’t pay. That means their ability to reinvest to expand or upgrade services to meet the area’s needs is reduced, Hegland said.


The owner of Prairie St. John’s, United Health Services of Pennsylvania, has invested $48 million to build the new 132-bed hospital, Herman said.

A backhoe and several stacks of pallets sit outside a new, rectangular building.
Construction continues on the new Prairie St. John's Hospital in downtown Fargo.
David Samson / The Forum

“How much should my company invest in the state of North Dakota,” if the state is unwilling to pay to expand behavioral health services for the needy, Herman said. During the last biennium, Prairie St. John’s had a “$2 million negative impact” that makes it hard to maintain services, he said.

If the state doesn’t pursue a Medicaid waiver, it should establish a voucher program to help as a payer of last resort for adults who can’t afford treatment, Hegland said.

North Dakota is facing an acknowledged serious shortage of behavioral health professionals, and the providers hope the state can invest to bolster workforce development in the field.

“Basically, our labor pool is flat,” Hegland said. “It’s going to be a tough battle.”

Herman said he hasn’t seen a plan to address the shortage of behavioral health workers.

Fortunately, Hegland said, behavioral health has gained “legislative champions.”

“I think we’ll have a pretty dynamic session,” he said. “We’ve got to take some bold initiatives.”

Patrick Springer first joined The Forum in 1985. He covers a wide range of subjects including health care, energy and population trends. Email address: pspringer@forumcomm.com
Phone: 701-367-5294
What To Read Next
Parents of Bismarck High School basketball players said no action was taken when the Jamestown student section acted out during the Jan. 31 game.
Professors peppered House Majority Leader Mike Lefor with questions during a virtual public forum about his bill to give certain college and university presidents more scrutiny over tenure process.
The death of former Attorney General Wayne Stenehjem was followed by the mass deletion of emails and the revelation of a budget overrun tied to a building leased from a state lawmaker.
Opponents worry about fiscal impact